Provider Demographics
NPI:1265594725
Name:PERRY, MICHAEL CHARLES
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHARLES
Last Name:PERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 UNION ST STE 200
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2694
Mailing Address - Country:US
Mailing Address - Phone:765-446-8808
Mailing Address - Fax:765-446-9567
Practice Address - Street 1:2020 UNION ST STE 200
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2694
Practice Address - Country:US
Practice Address - Phone:765-446-8808
Practice Address - Fax:765-446-9567
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120068261223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery